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cmt-uno > Headache > Flashcards

Headache Flashcards

1
Q

HA

Primary vs Secondary

A

Primary: Migraine (with or without aura), Tension, Cluster
-No known underlying cause
-90% of headaches are benign primary type

Secondary Headache: Brain tumors, aneurysms
-Symptoms of underlying disorder

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2
Q
A
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3
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A
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4
Q

Migraine

general

A

Common disorder
Women > Men

Boys < Girls (< 12yo more often seen in boys) -Increased with age, Abdominal migraines

Age 30-39
Though possible from child to elderly
Very old and very young uncommon

Familial/genetic component
Major cause of disability worldwide

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5
Q

Migraine

patho

A

Still developing theory
Genetic component – hyperexcited neurovascular system
Cortical spreading depression
Trigeminal nerve activation
Intracerebral vasodilation component

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6
Q

Migraine

S/Sx

A

Episodic disorder
Lasting minutes to days
Unilateral, usually
Retro-orbital
Pulsating
Photophobia / Phonophobia
Associated with nausea and vomiting
May be associated with aura
No persistent, hard neurological findings

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7
Q

Migraines

Types

A

Migraine with aura (classic migraine)
Less common

Migraine without aura (common migraine)
More common by 5:1

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8
Q

migraine

prodome

A

Yawning, euphoria, fatigue/depression, irritably, food cravings

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9
Q

Migraine

Aura

A

Aura is defined as a focal visual, sensory, or motor neurologic disturbance with a developing headache
Can include bright lines, shapes, tinnitus, noises, paresthesia, loss of vision, hearing, feeling or ability to move a part of the body
Increases in intensity over one to several hours, often unilateral, throbbing or pulsatile in quality
Common to report photophobia, phonophobia and cutaneous allodynia (perception of pain caused by normal activities i.e., wearing glasses)
Associated with ~25% of migraines (classic migraine)

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10
Q

Migarine

headache

A

Usually Unilateral throbbing, nausea, vomiting, photophobia, phonophobia

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11
Q

migraine

Scintillating scotoma

A

Scintillating scotoma – Aura spots that flicker between light and dark

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12
Q

HA

PE to do’s

A

Obtain blood pressure and pulse
Listen for bruits for clinical signs of arteriovenous malformation
Palpate the head, neck, and shoulder regions
Check temporal and neck arteries
Examine the spine and neck muscles

The neurologic examination should cover mental status testing, cranial nerve examination, funduscopy and otoscopy, and symmetry on motor, reflex, cerebellar (coordination), and sensory tests.

Gait examination should include getting up from a seated position without any support and walking on tiptoes and heels, tandem gait, and Romberg test.

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13
Q

Migraines

Dx

A

clinical

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14
Q

Migraine

criteria (w/o aura)

A

●(A) At least five attacks fulfilling criteria B through D
●(B) Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated)
●(C) Headache has at least two of the following characteristics:
*Unilateral location
*Pulsating quality
*Moderate or severe pain intensity
*Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
●(D) During headache, at least one of the following:
*Nausea, vomiting, or both
*Photophobia and phonophobia
●(E) Not better accounted for by another ICHD-3 diagnosis

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15
Q

criteria formigraine with aura

A

● At least two attacks fulfilling criterion B and C
● One or more of the following fully reversible aura symptoms:
*Visual
*Sensory
*Speech and/or language
*Motor
*Brainstem
*Retinal
●(C) At least three of the following six characteristics:
*At least one aura symptom spreads gradually over ≥5 minutes
*Two or more symptoms occur in succession
*Each individual aura symptom lasts 5 to 60 minutes
*At least one aura symptom is unilateral
*At least one aura symptom is positive
*The aura is accompanied, or followed within 60 minutes, by headache
●(D) Not better accounted for by another ICHD-3 diagnosis

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16
Q

migraine

abortive Tx

A
  • Nonpharmacologic/avoidance of triggers
  • NSAID & APAP
    Ketorolac
  • Triptans
    Sumatriptan (Imitrex)
    Rizatriptan (Maxalt)
  • Ergotamine
  • Dopamine antagonist & Diphenhydramine
    Metoclopramide (Reglan)
    Prochlorperazine
    Chlorpromazine (Thorazine)
  • Steroids
  • Fluids
  • Opioids
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17
Q

migraine

preventative

A

Topiramate (Topamax)
Valproate (Depakote)
Propranolol (Inderal)
Non-pharmacological/avoidance of triggers

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18
Q

Migraine

Special population Tx

A

Pregnant
Avoid ergotamine & NSAIDs
Antiepileptics NOT approved for migraine use
ACOG recommends Reglan (B) and Acetaminophen

< 12 yo – pediatric population considerations
Avoid Triptans
NSAIDs & APAP
Promethazine (Phenergan)
Propranolol for preventative

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19
Q

Tension headache

general

A

Most common type of headache
Bilateral, band or vice like
Pericranial muscle involvement
Nuchal rigidity?

No hard neurological findings

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20
Q

Tension HA

Types

A

Infrequent episodic
< 1 per month

Frequent episodic
1-14 per month

Chronic
> 14 per month

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21
Q

Tension HA

EPI

A
  • Most common type of primary headache
  • Universal, 86% of 12-41yo
    W > M, slightly
  • 2-3 times more common in kids as opposed to migraines
    Increases with age and is also higher in female kids
    Presentation similar to adults
  • Most people can identify a cause:
    Stress, fatigue, eye strain, myalgias, mild viral infections
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22
Q

Tension HA

features

A

Mild to moderate pain
Non-throbbing
Dull, pressure, band, tight hat
Pericranial muscle tenderness

No other associated features

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23
Q

tension

Dx

A

clinical

At least two of following:
Bilateral
Pressing or tight quality
Mild to moderate intensity
Not aggravated by routine physical activity

And, both of following:
No nausea or vomiting
No more than one of photophobia or phonophobia

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24
Q

Tension HA

acute Tx

A

NSAIDs & Acetaminophen
Ibuprofen, ketorolac, naproxen
Most common options for pediatric patients

Combination meds
Butalbital, APAP, Caffeine (Fioricet)

Migraine medications

Muscle relaxants (mixed data)

Opioids

Nonpharmacologic/avoidance of triggers

25
Q

Tension HA

Chronic Tx

A

NSAID
Amitriptyline
Nortriptyline
Fluoxetine
Muscle relaxant

Nonpharmacologic:
Physical therapy
Acupuncture
Avoidance of triggers

26
Q

Cluster HA

S/Sx

A

Unilateral
Non-pulsatile
EXTREME though brief episodes of pain in clusters of hours to days
Conjunctival injection
Rhinorrhea
Lacrimation
Facial swelling
Horner’s syndrome

27
Q

Cluster headache

Epidemiology

A

Rare < 1% of population
Male > Female, 4:1
Typically, 20-40 age range
Genetic link
Smoking

28
Q

Horner’s Syndrome

A

Miosis – constricted pupil
Ptosis – drooping of upper eye lid
Anhidrosis – absence of sweating on the face
Enophthalmos – sinking of eye into bony cavity

29
Q

Cluster HA

Dx

A

A sense of restlessness or agitation
Attacks have a frequency between one every other day and eight per day; during part (but less than half) of the active time-course of cluster headache, attacks may be less frequent

●At least five attacks
●Attacks characterized by severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15 to 180 minutes when untreated; during part (but less than half) of the time-course of cluster headache, attacks may be less severe and/or of shorter or longer duration

●Either or both of the following:
*At least one of the following symptoms or signs ipsilateral to the headache:
-Conjunctival injection and/or lacrimation
-Nasal congestion and/or rhinorrhea
-Eyelid edema
-Forehead and facial sweating
-Miosis and/or ptosis

30
Q

Cluster HA

Acute Tx

A

High flow oxygen first
Subcutaneous Sumatriptan if no response
Intranasal lidocaine as alternative treatment

31
Q

Cluster

Preventative

A

Verapamil and/or Steroids
Home O2
Avoidance of triggers?

32
Q

HA

red flags

A
33
Q

Causes of thunderclap headache

A
34
Q

Lumbar puncture

A

After the CT
Still needs to be done if your index of suspicion is high for SAH
Confirm for presence of RBCs and xanthochromia (bili) in CSF
Most sensitive 12 hours after SAH
Gives information regarding pressure, bleeding, infection

35
Q

‘Other’ headaches

A

Temporal arteritis/Giant cell arteritis
Cervical artery dissection
Abdominal migraine
Basilar / vestibular migraine
Ocular migraine
Trigeminal neuralgia
Occipital neuralgia
Venous sinus thrombosis
CO poisoning
Intracranial Mass
Post-traumatic (covered later)
Meningitis (covered later)

36
Q

Temporal Arteritis/Giant cell arteritis

general

A

Pathology
Inflammation of large to medium vessels
Remodeling can lead to vessel occlusion
Epidemiology
Age >50, Caucasian / Scandinavian, W>M

37
Q

giant cell arteritis

S/Sx

A

Symptoms
HA, scalp tenderness, temporal pain, jaw claudication, fever, amaurosis fugax (temp loss of vision)

38
Q

giant cell arteritis

Dx and Tx

A

Diagnosis
History and exam
ESR >50, CRP less sensitive
Biopsy

Treatment
Prednisone IV or PO, high dose
Immunosuppressive drugs

39
Q

GCA Headache

A

HA usually throbbing and continuous.
Focal tenderness on direct palpation typically present. Patient may note scalp tenderness with hair combing, or with wearing a hat or eyeglasses.

40
Q

GCA

Jaw claudication

A

Jaw claudication: fatigue or discomfort of the jaw muscles during chewing of firm foods or prolonged speaking.
Result of ischemia of maxillary artery supplying masseter muscles.
Highly predictive of temporal arteritis

41
Q

GCA

Vision

A

Around 50% experience visual symptoms
Initial visual symptoms may be transient and intermittent, typically unilateral visual blurring or vision loss.
Vision loss may not be reversible if treatment with steroids isn’t started immediately within the first few days

42
Q

GCA

polymyalgia rheumatica

A

About50% of patientswith GCA have underlying polymyalgia rheumatica (pain and stiffness of the shoulder and hip girdle)
About 15% with polymyalgia rheumatica develop GCA

43
Q

GCA

Tx

A

Steroids early to avoid permanent vision loss
High dosing of oral prednisone
Monitored for side effects

44
Q

Cervical artery dissection

general

patho and epi

A

Pathology
Separation of layers of the vessel
Major cause of morbidity is thrombi -> stroke

Epidemiology
Young
Associated with minor trauma, spontaneous, connective tissue disease

45
Q

Cervical artery dissection

Sx

A

HA progressive vs thunderclap, neck pain, ischemic changes

46
Q

Cervical artery dissection

Dx and Tx

A

Diagnosis: CTA, MRA

Treatment: Anticoagulation

47
Q

Migraine variants

Hemiplegic migraine

A

Unilateral weakness with migraine with aura attack

48
Q

Migraine variant

Abdominal migraine

A

Abdominal pain is primary complaint
Same triggers as migraines

49
Q

migraine variant

Vestibular migraine and Ocular migraine

A

Vestibular migraine
Vertigo associated with headache

Ocular migraine
Transient vison loss

50
Q

Occipital neuralgia

general

patho and Sx

A

Pathology
Entrapment of occipital nerve by scalp and neck muscle

Symptoms
Brief episodes of pain electric like pain in Occipital nerve distribution
Allodynia, can lead to occipital constant headache

51
Q

Occipital neuralgia

Dx and Tx

A

Diagnosis
Clinical, may consider CT / MRI

Treatment
Occipital nerve block
Carbamazepine
Gabapentin

52
Q

Venous sinus thrombosis

General

Patho and Epi

A

Pathology
DVT of brain
Leads to ischemic changes, disruption of BBB
Epidemiology
W>M, pregnancy, thrombophilia

53
Q

Venous sinus thrombosis

Sx

A

Headache, nausea, vomiting, seizure, drowsy

54
Q

Venous sinus thrombosis

Dx and Tx

A

Diagnosis: MRV, D-dimer, thrombophilia screen

Treatment: Anticoagulation, endovascular

55
Q

Carbon monoxide poisoning

A
56
Q

Intracranial Mass

Epi

A

Occurs during course of disease within 40-60% of patients
MC masses include gliomas, meningiomas, and pituitary adenomas

57
Q

intracranial mass

Sx

A

Vary widely due to size and location of mass
Nausea and vomiting may be seen
Moreso tension-type headache
Red flags in history such as fever, neurologic signs, over age 50, etc.

58
Q

intrcranial mass

Dx and Tx

A

Diagnosis
MRI exceeds CT imaging for tumors

Treatment
Depends on tumor type, status of patient, and extent of disease
Early – glucocorticoids and simple analgesics

cmt-uno (54 decks)

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